PERBANDINGAN KELENGKAPAN PENGISIAN REKAM MEDIS ANTARA DOKTER SPESIALIS DI PAVILIUN GARUDA DAN RESIDEN DI BANGSAL PENYAKIT DALAM RSUP dr. KARIADI SEMARANG PERIODE AGUSTUS 2010

Abstract

Background : Incomplete medical record document became a problem because its often represent the only one note which gave the detail information about everything was happened and conducted during patient taken care at hospital. From the survey result, descriptively indicate that there is difference between number of medical record completeness, both of Pavilion Garuda specialist's medical record and internal medicine ward doctors’s. The aim of this research is to analizes the comparison of medical record completeness between Pavilion Garuda specialists and doctors in internal medicine ward RSUP DR Kariadi Semarang . Method : Research methode used is analytical survey with the approach of cross sectional study. Research methode used is medical record document in August 2010 with the detail 50 Paviliun Garuda's medical record documents and 50 internal medicine ward's. Result : Descriptive analysis results showed differences in the completeness of filling of medical records between Pavillion Garuda specialists and resident in the internal medicine ward . Of the 100 medical records of the study sample, showed the completeness of filling of medical records by a Pavillion Garuda specialist at 41.61% while the completeness of filling of medical records by a resident in internal medicine ward at 76.46%, where the results obtained charging the completeness of medical records by aPavillion Garuda specialist lower than by the resident in internal medicine. Conclusion : The results obtained by the completeness of filling the medical records by Pavillion Garuda specialist was lower than by internal medicine resident Keyword : Completeness, medical record 1.Undergraduate Student of Medical Faculty of Diponegoro University 2.Lecture of Forensic Department of Medical Faculty of Diponegoro University